Decision to delivery interval for emergency caesarean section in Eastern Uganda: A cross-sectional study

Introduction The decision to delivery interval is a key indicator of the quality of obstetric care. This study assessed the decision to delivery interval for emergency cesarean sections and factors associated with delay. Methods We conducted a cross-sectional study between October 2022 and December 2022 in the labor ward at Mbale regional referral hospital. Our primary outcome variable was the decision to delivery interval defined as the time interval in minutes from the decision to perform the emergency caesarean section to delivery of the baby. We used an observer checklist and interviewer administered questionnaire to collect data. Stata version 14.0 (StataCorp; College Station, TX, USA) was used to analyze the data. Results We enrolled 352 participants; the mean age was 25.9 years and standard deviation (SD) ±5.9 years. The median (interquartile range) decision to delivery interval was 110 minutes (80 to 145). Only 7/352 (2.0%) participants had a decision to delivery time interval of ≤30 minutes. More than three quarters 281 /352 (79.8%) had a decision to delivery interval of greater than 75 minutes. Emergency cesarean section done by intern doctors compared to specialists [Adjusted Prevalence Ratio (aPR): 1.26; 95% CI: (1.09–1.45)] was associated with a prolonged decision to delivery interval. Conclusion The average decision to delivery interval was almost 2 hours. Delays were mostly due to health system challenges. We recommend routine monitoring of decision to delivery interval as an indicator of the quality of obstetric care.


Introduction
Globally, 810 women die to pregnancy related complications and over 6,700 newborns die every day [1,2].Sub-Saharan Africa accounts for 70% of global maternal deaths and 43% of global newborn deaths [1,3].In Uganda, maternal mortality ratio is 284 deaths per 100,000 live births [1] while the neonatal mortality rate is 19 deaths per 1,000 live births [4].This is higher than the Sustainable Development Goal (SDG) target of less than 70 maternal deaths per 100,000 live births and 12 neonatal deaths per 1,000 live births [5].The reported 24-fold difference in intrapartum-related neonatal mortality between high-income and low-income countries shows that improving the quality of obstetric care can effectively reduce maternal and perinatal mortality [6].Over 22,000 intrapartum related maternal deaths and 1.9 million perinatal deaths that occur annually could be prevented by improving the quality of obstetric care in LMIC [6].
Decision to delivery interval is a key indicator of quality of obstetric care and affects perinatal outcomes [7,8].Decision to delivery interval is the duration from time when the decision to birth a baby by emergency cesarean section to the time the baby is birthed [9,10].The world Health Organization (WHO) recommends a decision to delivery interval of 30 to 75 minutes depending on the context [11].However, data from developing countries shows almost 30% of emergency caesarean sections were performed within 30minutes of the decision to deliver [12].
Mbale regional referral hospital is a high volume facility with 12,000 births per year and of these 35% are by caesarean sections [13].Out of every 1,000 women who under-go an emergency caesarean section in Mbale regional referral hospital, 102 experience a perinatal death.A possible explanation for the high perinatal deaths in Mbale regional referral hospital and other similar health facilities in low and middle-income countries could be poor obstetric care.One of the recommended indicators of the quality of obstetric care is decision to delivery interval.Unfortunately, decision to delivery interval is not routinely documented in low and middle countries, Therefore, we aimed to assess the decision to delivery interval for emergency cesarean section as a marker of quality of obstetric care at Mbale regional referral hospital.

Study design
We conducted a cross-sectional study between October 2022 and December 2022.

Study setting
We conducted this study within the labor ward of Mbale regional referral hospital in Eastern Uganda between October 2022 and December 2022.This hospital serves a population of about four million people from 16 districts and one city.Mbale regional referral hospital is the main referral center for four district hospitals and ten health sub-districts in and around Mount Elgon zone.Annually, 12,000 deliveries are registered at Mbale regional referral hospital and cesarean section rate is 35% [13].It has a capacity of 470 beds.The Obstetrics and Gynecology department has 3 specialists, 2 medical officers, 21 midwives and 8 intern doctors.The labor suite has 6 functional delivery beds and 1 operating theater table and an average of 6-7 emergency cesarean sections daily.

Study population
Participants were pregnant women who gave birth by emergency cesarean section at Mbale regional referral hospital between October 2022 and December 2022.

Inclusion criteria
Women at 37 weeks of gestation and above who had to give birth by emergency cesarean section were included in the study.

Exclusion criteria
Pregnant women admitted in the labor ward with preterm premature labor and needed to deliver by emergency caesarean section as well as women with mental illness were excluded from the study.

Operational definitions
Decision to delivery interval.Time from decision of the emergency cesarean section to delivery of the fetus [14].
No delayed decision to delivery interval.Is a decision to delivery interval of less than or equal to 75 minutes.
Prolonged decision to delivery interval.Is decision to delivery interval of more than 75 minutes.

Routine practices in a Ugandan hospital
A woman with labor-like pains is admitted by a midwife at the labor suit.The midwife triages, examines and monitors the progress of labor.A team of medical doctors and specialists do a ward round every morning to review mothers in labor and assess for need to deliver by caesarean section.The decision to deliver by caesarean section is made by the most senior doctor on the ward round with consultation from an available senior midwife.Notes are made in the patient's file by the junior doctors attending the ward round.Time and date of decision to deliver by caesarean section is documented.The junior doctor obtains consent from the mother for the operation.The midwife on duty prepares the patient for the caesarean section.Preparation involves blood grouping and cross matching, inserting urinary catheter, administering intravenous fluids, pre-operative antibiotics.
The anesthesia team reviews the woman preoperatively.The woman is wheeled to theater as soon as theater space is available.In the theater, the anesthetist documents the various times on an anesthesia chart.The different times include:-time of administration of the anesthetic agent, time of start of the operation, time of skin incision, time of end of operation.Midwife receiving the baby documents the time of delivery of the baby.After the caesarean section, the junior doctor documents the entire procedure of the emergency cesarean section in the patient's file as dictated by the main surgeon of the operation.

Study procedure
A research assistant screened mothers for eligibility at the time when a doctor recommended birth by emergency cesarean section in the labor ward.Mothers who were found eligible were consented and enrolled into the study.The research assistant recorded the time when a doctor recommended birth by emergency cesarean section.The mothers were followed up to theatre and the midwife noted the time when the baby was delivered.The decision to delivery interval was determined by calculating the duration between decision to birth by cesarean to the time the baby was birthed.A questionnaire was used to collect information on sociodemographic, obstetric and system factors that may have affected decision to delivery interval.

Sample size and sampling procedure
We estimated the sample size of this study using Cochran's Formula for 95% confidence interval, 5% precision and 35.5% of women who had emergency cesarean section within one hour of decision to delivery in Nsambya Hospital in Uganda [15].This gave us an estimated sample size of 352 participants.Participants were sampled consecutively until the sample size was reached.This involved identifying women sanctioned for emergency cesarean section at the labor suite unit and following them up to when they are taken to the operating theater and later in the in-patient postnatal unit.We defined an emergency cesarean section as a surgery that is conducted when there is an immediate threat to the life of the mother and fetus [16].

Main variables
Outcome variable.The primary outcome was the decision to delivery time interval defined as the time measured from the decision to do an emergency cesarean section to delivery of the fetus [17].
Exposure variables.We collected data on socio-demographic factors such as age, marital status, education level, occupation, place of residence, religion, and presence of relatives to give consent.We also collected data on obstetric factors such as ANC visits, previous caesarean section, gravidity, parity, referral status, weight, height, body mass index, and gestational age.Our health system factors included availability of surgical materials and other logistics, type of anesthesia used, time of operation, human resource shortage, busy operating theater, cadre of surgeon and type of anesthesia.
Data collection.We developed a questionnaire which consisted of an observational checklist and structured interview questions.This tool developed was piloted on 35 (10%) women who underwent an emergency cesarean section from Namatala health center IV and revised accordingly in order to meet the study objectives before a final copy was sent for approval from the research ethics committee.The consent form was both in English and the local dialect within the study area.Working together with the principal investigator, two research assistants who work in the labor suite as registered midwives of the hospital were trained on the process of data collection and they collected data during day and night.
Data analysis and management.The continuous variables were summarized as means and standard deviations or median and inter-quartile ranges as appropriate, while the categorical variables were presented as frequencies and percentages.Data were analyzed using Stata software version 17.0 (StataCorp; College Station, TX, USA) for analysis.
We conducted bivariable and multivariable analyses using a generalized linear model for the Poisson family with a log link to assess the strength of association using prevalence ratios between selected exposures and delay.Variables included in the multivariable model were based on biological plausibility and literature review.

Maternal and perinatal outcomes among women who had emergency caesarean sections at Mbale regional referral hospital
All mothers were alive after the emergency caesarean section.Only 32/352 (9.1%) required blood transfusion.Majority of the babies delivered by emergency caesarean section were alive and well 294/352 (83.52%).Only 20/352 (5.7%) were born dead or were an early neonatal death.The details are in Table 3.

Factors associated with prolonged decision to delivery interval
Emergency cesarean section done by intern doctors compared to specialists [Adjusted Prevalence Ratio (aPR): 1.26; 95% CI: (1.09-1.45)]was associated with prolonged decision to delivery interval.The details are in Table 4.

Discussion
We found 80% of emergency cesarean sections having prolonged decision to delivery interval of more than 75 minutes.Hardly any of the emergency cesarean sections were done within the  recommended 30 minutes of decision to delivery interval.Less than a quarter had an emergency cesarean section done within the 75 minutes that is deemed acceptable for resource constrained settings.Cadre of the doctor who performed the cesarean section was associated with prolonged decision to delivery interval.The decision to delivery time in this study was prolonged with a median decision to delivery interval of 110 minutes.This finding of a prolonged decision to delivery interval is not really surprising because similar studies done in Uganda and other Sub-Saharan countries also found the proportion of mothers with a decision to delivery interval of at most 30minutes to be 2% or less i.e. 0.7% in Nsambya, 2% in Mulago, 0.9% in Nigeria 1.7% in Ghana.This may be due to similarities in the health system that is usually characterized by high patient numbers, low staffing and often stock outs of medical supplies needed for emergencies cesarean sections [15,[18][19][20][21].As a referral center with a catchment population of over five million people, the hospital receives a high volume of patients with emergencies from lower health facilities compared to the available health workers and facilities [18,22].For instance, the hospital has only one operating table dedicated for emergency obstetric surgeries, which makes it impossible to perform several surgeries at ago.Furthermore, this mismatch between patient volumes and available facilities contributes to the chronic stock out of essential commodities such as drugs and sundries [23].Lack of surgical supplies further contributes to the preoperative delays even when the theater space is available because patients have to buy them out of pocket.
Decision to delivery interval outside working hours (00:00hours and 08:00hours) was prolonged.This is similar to a study in Germany [24] and can be explained by it being night time when not only the doctor on call is sleeping but also majority of the pharmacies where the surgical logistics are bought are closed.The prolonged decision to delivery interval at 17:00hours and between 20:00hours and 21:00 hours can be attributed to the change in shift whereby there is handover process of the ward that involves various aspects such as report writing, counting of the equipment and patient handover.Furthermore, the prolonged decision to delivery interval at lunch time can be attributed to midwives and doctors spending time having lunch.Emergency Cesarean sections performed by medical officers and Obstetricians were 26% less likely to have a prolonged decision to delivery interval compared to those by intern doctors.Our results are consistent with findings from India and Ethiopia that reported association between surgery performed by obstetrician and shorter decision to delivery time interval [10,16].The possible explanation is medical officers and obstetricians have more clinical experience, quicker decision making unlike the intern doctors undergoing training.

Strengths and limitations
This is the first study determining decision to delivery time in eastern Uganda in Mbale regional referral hospital.
Our study was limited by the fact that the research assistants and midwives on the ward and in theatre did not have standardized timers or clocks to record the time of decision making and birth of the baby.
We were also unable to accurately measure the theatre waiting time, time taken to give anesthesia and time taken to perform surgery to birth the baby.This was due to shortage of staff and high number of patients attended to by the hospital.Since the study was funded by the principal investigator, only a few research assistants were employed.